Tennessee State University
Authorization for Direct Deposit of Pay
NAME:
SSN:
DATE:
I previously submitted an authorization for Direct Deposit of Pay and that information is still correct.
Authorization for Direct Deposit of Pay
Primary Account – Direct Deposit NET PAY Amount:
Name of Financial Institution:
Account Type:
Checking
(check one)
Savings
Financial Institution Routing Number:
Account Number:
Secondary Account – Direct Deposit FIXED PAY Amount:
Name of Financial Institution:
Account Type:
Checking
(check one)
Savings
Financial Institution Routing Number:
Account Number:
Fixed Dollar Amount $
Bi-Monthly Paycheck
Monthly Paycheck
Check if this is a Change
I hereby authorize Tennessee State University to direct the net amount and/or fixed dollar amount of my salary and
wage payments to my bank account(s) as shown above, effective on the next payroll possible. A preprinted voided
check is attached for verification purposes. This authorization is not an assignment of my right to receive payment
and revokes all prior payment direction notifications applicable to these payments. I understand that this request may
be canceled or changed by me upon proper execution of another authorization agreement. I also understand that this
authorization may be terminated at any time by the University, or named financial institution. I authorize Tennessee
State University to initiate withdrawal transactions from my account in the event of an overpayment or erroneous
deposit.
Date:
Employee Signature: